LEC 10.1: Comfort & Pain Management

Pain

Whatever the person says it is and exists whenever he says it does

Highly subjective, based on experience of client

Pain

Unpleasant sensory and emotional experience associated with actual or potential tissue damage

1. Pain is a physical and emotional experience

2. It is in response to actual or potential tissue damage

3. It is described in terms of such damage

3 parts have important implication

Pain is a physical and emotional experience

One of the 3 parts that have important implication

Pain is not just all in the body and mind

It is in response to actual or potential tissue damage

One of the 3 parts that have important implication

Example: Radiographic or laboratory result is normal, but the pain is real in the patient

It is described in terms of such damage

One of the 3 parts that have important implication

Pain can be described through location, duration, intensity, etiology

1. Chemical

2. Thermal

3. Mechanical

Types of pain stimuli

Mechanical

Type of pain stimuli

Cuts, Physical Injuries

Thermal

Type of pain stimuli

By cold or heat

Chemical

Type of pain stimuli

In blood vessels, have blocking of blood flow, which can cause pain

Production of lactic acid when muscles tear

Pain Management

Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client

1. Location

2. Duration

3. Intensity

4. Etiology

Types of Pain

Location

Type of pain

Classification of pain based on where it is in the body

Example: Head, Knee, Chest

1. Radiate

2. Referred

3. Visceral

Within Location, what factors needs to be considered?

Radiate

Within Location, factor that needs to be considered

Spread or extend

Radiate

Identify the type of pain based on Location

Severe chest pain that ___ down the left arm and jaw, which indicates a Myocardial Infarction. Pain from the heart __ to other parts of the body.

Referred

Within Location, factor that needs to be considered

Appear to arise in different areas

Referred

Identify the type of pain based on Location

Patient with history of gallstones presents to hospital with intense pain in right shoulder and upper back. Pain is ___ from the irritation of the gallbladder (Biliary Colic). Original source of the pain is the inflammed gallbladder but it is not there where the pain is felt, rather the upper back and right shoulder.

Right Leg

When Kidney Punch Test is conducted, where else can pain be illicited?

• Right Neck

• Right Shoulder

Other than directly in the liver, pain from the liver can be referred to where?

Visceral

Within Location, factor that needs to be considered

Arising from organs or hollow viscera

Visceral

Identify the type of pain based on Location

Patient is admitted with acute appendicitis, experiencing diffused, poorly localized abdominal pain. Pain is all over the abdomen. Arises from the inflammation of the appendix and is described as deep, cramp-like pain.

Duration

Type of pain

Either Acute or Chronic

1. Acute

2. Chronic

Classifications for Duration

Acute

Classifications for Duration

Lasts only through the expected recovery period; whether it has a sudden or slow onset and regardless of intensity.

Less than 3 months

Less than 3 Months

What is the duration of Acute Pain?

Chronic

Classifications for Duration

Prolonged, usually recurring or persisting over 3 months or longer, and interferes with daily functioning

From injury or illness

More than 3 Months

What is the duration of Chronic Pain?

Intensity

Type of pain

Classified as either Mild, Moderate, or Severe

1-3

What is the pain rating for Mild Pain?

4-6

What is the pain rating for Moderate Pain?

7-10

What is the pain rating for Severe Pain?

Etiology

Type of Pain

Classified as either Physiological or Neuropathic

Nociceptive Pain

What is Physiological Pain also known as?

Physiological/Nociceptive Pain

Classification of Etiology

Experience when intact properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care

Subcategories: Somatic or Visceral

1. Somatic

2. Visceral

What are the subcategories of Physiological Pain?

Somatic

Subcategory of Physiological Pain

Originates in the skin, muscles, bone, or connective tissues

Visceral

Subcategory of Physiological Pain

Pain wherein it arises from organs or hollow viscera

Neuropathic Pain

Classification of Etiology

Damaged or malfunctioning nerves

Subcategories: Peripheral, Central, or Sympathetic

1. Peripheral

2. Central

3. Sympathetic

What are the subcategories of Neuropathic Pain?

1. Pain Threshold

2. Pain Tolerance

3. Hyperalgesia & Hyperpathia

4. Allodynia

5. Dysesthesia

Concepts Associated with Pain

Pain Threshold

Concept Associated with Pain

Least amount of stimuli to feel pain

Wala pa ang pain. You have the stimulus and when you start to recognize it as painful

Pain Tolerance

Concept Associated with Pain

Maximum amount of pain stimuli that a person is willing to withstand without seeking avoidance of the pain or relief

Pain is already there.

Pain Tolerance

The following is an example of what:

Mother giving birth is experiencing Labor Pain but refuses to take medications to have a greater drive to push and to avoid the baby from becoming drowsy, withstanding the pain.

Hyperalgesia & Hyperpathia

Concept Associated with Pain

Use interchangeably to denote a heightened response to a painful stimuli

Intense reaction to pain stimuli

Hyperalgesia & Hyperpathia

The following is an example of what:

A person may experience intense pain to a painful stimuli that typically illicits only a mild response or no response.

Allodynia

Concept Associated with Pain

Non-painful stimuli produce pain

Exaggerated response to a painful stimuli

Allodynia

The following is an example of what:

A person receives light touch and experiences pain.

Dysesthesia

Concept Associated with Pain

Unpleasant abnormal sensation

Either spontaneous or evoked

Nociception

Physiologic process related to pain perception

1. Transduction

2. Transmission

3. Perception

4. Modulation/Descending System

4 Processes of Nociception

1. Transduction

Part of the process of Nociception

1. Injury

2. Harmful stimuli triggers release of biochemical mediators/neurotransmitters, including prostaglandins, histamine, serotonin, substance P, which synthesize the nociceptors

3. Causes movement of ions across the cell membrane, exciting the nociceptors (pain receptors)

4. At this phase, non-opioid medications can work, like those that inhibit prostaglandin release

2. Transmission

Part of the process of Nociception

1. Includes 3 segments:

   1. Pain impulses travel from peripheral nerve fibers to dorsal horn of spinal cord – substance P serves as a neurotransmitter that enhances the movement of impulses across the nerve synapse from the primary afferent neuron to the second order neuron in the dorsal horn of the spinal cord

   2. Pain signals transmit through an ascending pathway in the spinal cord to the brain

   3. Transmission of the information to the brain where pain perception occurs

2. Opioids can especially work in this phase, which block the release of neurotransmitter, Substance P, which stops the pain at the spinal level

3. Perception

Part of the process of nociception

1. Client becomes conscious of the pain; how they interpret pain

2. Sum of complex activities in the CNS that may shape the character and intensity of pain perceived

   1. Example: Sharp, burning pain, intense pressure

   2. Gives meaning to the pain

4. Modulation

Part of the process of nociception

1. Part of descending system/often described as the descending system

2. Final process that occurs when neurons in the brain send signals back down to the dorsal horn of the spinal cord and the descending fibers release substances like endogenous opioids, serotonin, and norepinephrine which can inhibit or reduce the ascending pain pulses in the dorsal horn

3. Modulates/reduces the pain

4. Since the released substances are absorbed back, there is still pain felt, it is just modulated

Melzack & Wall

Who proposed the Gate Control Theory?

Gate Control Theory

Theory that proposes non-painful sensations can block painful ones, helping to reduce pain perception

Through non-painful sensations, such as rubbing or massage

According to the Gate Control Theory, how is pain alleviated?

• Physiologic

• Psychosocial

What are the aspects of the human response to pain?

1. Ethnic & Cultural Values

2. Developmental Stage

3. Environment & Support People

4. Past Pain Experiences

5. Meaning of Pain

6. Emotional Response to Pain

Factors Affecting the Pain Experience

Ethnic & Cultural Values

One of the Factors Affecting the Pain Experience

• Behavior related to pain is a part of the socialization process.

• Cultural background can affect the level of pain that an individual is willing to tolerate.

Development Stage

One of the Factors Affecting the Pain Experience

• An important variable that will influence both the reaction and the expression of pain.

• Doesn’t mean that children or the very young infants feel pain - They’re more expressive when they are in pain even though they can’t verbalize it

Environment & Support People

One of the Factors Affecting the Pain Experience

• Usually when the person in pain is surrounded by people, they can get distracted and lose their attention to pain

• However, a lonely person may perceive pain as severe since they don’t have much of a distraction

• A strange ___ can compound pain

  • New to a certain area in the hospital, sound by machines or other people, may cause more discomfort

Past Pain Experiences

One of the Factors Affecting the Pain Experience

• People who have personally experienced pain or who have been exposed to the suffering or someone close are often more threatened by anticipated pain than people without a pain experience.

• Because they have experienced it before, they anticipate it and the anxiety will build up causing more discomfort

Meaning of Pain

One of the Factors Affecting the Pain Experience

• A client who associates pain with a positive outcome may withstand the pain well.

• Client with unrelenting chronic pain may suffer more intensely.

Emotional Response to Pain

One of the Factors Affecting the Pain Experience

• Anxiety often accompanies pain. If anxiety is prolonged, depression, difficulty coping, the fear of the unknown, fear of inability to control pain

• That may affect their response to pain, creating fatigue which reduces their ability to cope and increases the pain perception

1. Infant

2. Toddler & Preschooler

3. School-Age Child

4. Adolescent

5. Adult

6. Elder

Age Variation Categories in Pain Experience

Infant

Age Variation Category in Pain Experience

• Perceives pain

• Respond to pain with increased sensitivity

• Older ___ tries to avoid pain for example, turns away and physically resists

• Glucose Pacifier

• Tactile stimulation/White Noise

Interventions to alleviate pain in Infants

Toddler & Preschooler (1-3 y.o.)

Age Variation Category in Pain Experience

• Develops the ability to describe pain and its intensity and location

• Often responds with crying and anger because they perceive pain as a threat to security

• Reasoning with __ at this stage is not always successful

• May consider pain as a punishment

• Feel sad

• May learn there are gender differences in pain

• Tends to hold someone accountable for the pain

• Distract with toys, books, pictures

• Blow bubbles (“Blow pain away”)

• Appeal to child’s belief in magic by using a “magic” blanket to take away the pain

• Explore misconceptions about pain

Interventions to alleviate pain in Toddler & Preschooler

School-Age Child

Age Variation Category in Pain Experience

• Tries to be brave when facing pain

• Rationalizes in an attempt to explain the pain

• Responsive to explanations

• Can usually identify the location and describe the pain

• With persistent pain, may regress to an earlier stage of development

• Use imagery to turn off “pain switches”

• Provide a behavioral rehearsal of what to expect and how it will look and feel

• Provide support and nurturing

Interventions to alleviate pain in School-Age Child

Adolescent

Age Variation Category in Pain Experience

• Slow to acknowledge pain

• Recognizing pain or “giving in” may be considered as weakness

• Wants to appear brave in front of peers and not report pain

• Provide opportunities to discuss pain

• Provide privacy

• Present choices for dealing with pain

• Encourage music or TV for distraction

• Massage, acupressure

Interventions to alleviate pain in Adolescents

Adult

Age Variation Category in Pain Experience

• Behaviors exhibited when experiencing pain may be gender-based behaviors learned as a child

• May ignore pain because to admit it is perceived as a sign of weakness of failure

• Fear of what pain means may prevent some ___ form taking action

• Focus on the client’s control in dealing with the pain

• Allay fears and anxiety when possible

Interventions to alleviate pain in Adults

Elder

Age Variation Category in Pain Experience

• May have multiple conditions presenting with vague symptoms

• May perceive pain as part of the aging process

• May have decreased sensations or perceptions of the pain

• Lethargy, anorexia, and fatigue may be indicators of pain

• May withhold complaints of pain because of fear of the treatment, of any lifestyle changes that may be involved, or of becoming dependent

• May describe pain differently, as “ache”, “hurt”, or “discomfort”

• May consider it unacceptable to admit or show pain

• Thorough history and assessment is essential

• Spend time with the client and listen carefully

• Clarify misconceptions

• Encourage independence whenever possible

Interventions to alleviate pain in Elder

Pain Assessment

What is considered the Fifth Vital Sign?

1. Pain history to obtain from the client (COLDSPA)

2. Direct observation

What are the two major components for assessing pain?

Characteristic

Onset

Location

Duration

Severity

Pattern

Associated Signs & Symptoms

COLDSPA

Direct Observation

The following situation exemplified which major components of pain assessment?

Comatose patient cannot speak whether in pain or not so the nurse should take the vital signs and assess other symptoms, like increased HR, increased BP, diaphoretic (increased sweating).

• Location

• Related Factors

• When Known

• Either Acute (<3 months) or Chronic (>3 Months)

What should be taken into account when Diagnosing Pain?

• Ineffective Airway Clearance related to weak cough secondary to postoperative incisional abdominal pain.

• Hopelessness related to feelings of continual pain

• Anxiety related to past experiences of poor control of pain and anticipation of pain.

• Ineffective Health Maintenance related to chronic pain and fatigue

• Self-Care Deficit (Specify the ADL Affected) related to poor control of pain.

• Deficient Knowledge (Pain Control Measures) related to lack of exposure to information resources.

• Impaired Physical Mobility related to arthritic pain in knee and ankle joints

• Insomnia related to increased pain perception at night

• Ineffective coping related to prolonged continuous back pain, ineffective pain management, and inadequate support systems and anxiety related to poor control of pain and anticipation of pain

Examples of Diagnosis related to the problem of pain (Best to Write Out these Diagnoses)

Planning

Established goals will vary according to the diagnosis and its defining characteristics

Pain is on a case to case basis

Depends on the pain’s defining characteristics:

• Somatic or Visceral

  • Somatic pain originates on skin, muscle, bone, like a paper cut. Visceral pain is on the deeper level, like liver pain and angina pectoris, a cardiac pain, or irritable bowel.

• Neuropathic

  • For neuropathic pain, Postherpetic neuralgia is pain felt by patients that have experienced herpes zoster like shingles and chicken pox, which may last longer due to malfunctioning nerves. Can be a painful, numbness, electric shock or burning.

• Type of stimulus

  • Mechanical: trauma, injury, tumor, alteration in the body tissue like edema, blockage of body duct, muscle spasm

  • Thermal: cold or hot

  • Chemical: tissue ischemia/blocked coronary artery, muscle spasm like lactic acid being produced

Muscle Spasm

What type of pain stimulus can be considered either Mechanical or Chemical?

Implementation

What portion of nursing management is pain management a part of?

1. Pharmacologic

2. Nonpharmacologic

What are the 2 basic types of nursing interventions?

Pharmacologic Interventions

One of the 2 basic types of nursing interventions

Giving medications

Non-Pharmacologic Interventions

One of the 2 basic types of nursing interventions

Interventions that do not rely on medications

Level I: Nonopioid (& Adjuvant)

Component of the Ladderized Treatment of Pain

For pain that is persistant, giving analgesics or OTC medications, like paracetamol, ibuprofen, acetaminophen, acetylsalicylic acid, celecoxib, naproxen, as well as a support.

• paracetamol

• ibuprofen

• acetaminophen

• acetylsalicylic acid

• celecoxib

• naproxen

Examples of Nonopioids

Level II: Opioid for mild moderate pain (& Nonopioid + Adjucant)

Component of the Ladderized Treatment of Pain

If pain is mild or moderate wherein it’s persistent, this may be given, including hydrocodone, codeine, tramadol, and buprenorphine.

Level III: Opioid for severe pain (& Nonopioid + Adjuvant)

Component of the Ladderized Treatment of Pain

If pain is severe, this may be given, including fentanyl, hydromorphone, methadone, morphine sulfate, oxycodone, oxymorphone.

• fentanyl

• hydromorphone

• methadone

• morphine sulfate

• oxycodone

• oxymorphone

Examples of Opioids for Severe Pain

• Establishing a trusting relationship.

• Consider the client’s ability and willingness to participate actively in pain relief measures.

• Use a variety of pain relief measures

• Provide measures to relieve pain before it becomes severe.

• Use pain-relieving measures that the client believes are effective.

• Try ineffective pain relief again before abandoning it

• Maintain an unbiased attitude

• Prevent harm to the client.

• Educate the client and caregiver about pain.

Important Factors to Consider in Implementing

Establishing a trusting relationship

Important in Implementing

• When a person is pain, there is always anxiety so this must be done to lessen that

Assess client’s ability and willingness to participate

Important in Implementing

• Should be done most especially in nonpharmacologic treatment